Research has amply demonstrated that the two most important
tasks for the anaesthetist are management of the difficult airway and
maintenance of oxygenation. Respiratory problems are still the most important
single cause of anaesthetic adverse events leading to a bad outcome. The true
number of these cases is likely to be significantly greater than those
published. The question of what to do after failed intubation in the paralysed
patient is a daily business. Thus, one could be forgiven for presuming that
guidelines for its management are fairly standardised. Unfortunately, this is
not the case. This article sets out some useful guidelines for practitioners to
ensure best practice.

Should one be at a loss as to what procedure to follow after failed
intubation in the paralysed patient, the first fundamental question is whether you
can oxygenate the patient. If the answer is yes, you can consider your
preferred technique on how to manage this particular problem. Deciding which
supraglottic airway device is used should be based on the following parameters:
1. Clinical evidence;

2. Incidence of major and minor laryngeal morbidities;

3. Limitation in this special situation; and,

4. Availability, experience and hence preference of the user.

The key point is that only a sufficient range of proven
techniques should be practiced every day to facilitate successful use in
emergencies.

Failed Intubation – Different
Recommendations

Recommendations of the different national societies differ
significantly in their advice on best practice in managing an unpredicted
difficult airway where oxygenation is still possible. In Table 1 you can see a
few examples for comparison purposes.

Dealing with the Worst Case Scenario

If you cannot oxygenate your paralysed patient you will need
guidelines and practice to avoid fatality. Despite the rarity of this scenario,
it is the duty of the anaesthetist to know how to manage a ‘cannot intubate’
and ‘cannot ventilate’ scenario. In many cases, the disaster will have begun with
a difficult mask ventilation and not directly with a ‘cannot intubate’ and
‘cannot ventilate’ situation. One of the most important reasons why this
happens is that it has not been realised or accepted that this particular
patient is impossible to intubate conventionally, and thereby the practitioner
may continue to attempt intubation.

Table 2 shows different recommendations of how to manage a
difficult mask ventilation that may potentially result in an airway disaster.

Conclusion

Despite the various recommendations published on how to manage a
difficult airway, we must not forget that the steps involved in this critical
treatment process will always be a practical matter that is subject to the
individual variations of the situation. As anaesthetists and intensive care
physicians, it is our obligation to gain and maintain the necessary skills, and
to be prepared to manage rare life-threatening situations. As a consequence,
the number of instruments should be limited to only a few proven techniques.
These techniques should be used in the daily routine or at least in workshops.

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